Lecture 2

V550V550

The Health Interview:The Health Interview:Facilitating QuestionsFacilitating Questions

Richard E. Meetz, OD, MSRichard E. Meetz, OD, MS20082008

Facilitating QuestionsFacilitating Questions

Questions Facilitation: Promoting Questions Facilitation: Promoting communication through verbal or communication through verbal or non-verbal meansnon-verbal means

The patient is encouraged to speak, The patient is encouraged to speak, but no direction is provided.but no direction is provided.

Facilitating QuestionsFacilitating Questions

The interviewer makes use of The interviewer makes use of gestures, facial expressions, an gestures, facial expressions, an attentive manner and a few words to attentive manner and a few words to urge the patient to continue urge the patient to continue discussion. discussion.

Facilitation: Facial ExpressionsFacilitation: Facial Expressions

Nod of the head:Nod of the head:

– Means “Go on, I’m listening”; “I heard Means “Go on, I’m listening”; “I heard you”you”

– Beware of the “Nervous Nod”Beware of the “Nervous Nod” “ “Constant Nod” or “Bobble Head Nod” -Constant Nod” or “Bobble Head Nod” -

Misleading and looks sillyMisleading and looks silly


Perplexed Facial ExpressionsPerplexed Facial Expressions– Raised eye brow, pursed lips etc...Raised eye brow, pursed lips etc...

– Means “I don’t understand you”, “I can’t Means “I don’t understand you”, “I can’t follow you”, “Does not make sense”follow you”, “Does not make sense”

– Beware these can be interpreted as Beware these can be interpreted as disapprovaldisapproval


Head shake:Head shake:– Can mean disapproval or unbelievableCan mean disapproval or unbelievable– ““Does not sound correct”, “Not possible” Does not sound correct”, “Not possible” – ““Not good”Not good”

Frown: aboveFrown: above

Raised eye brows:Raised eye brows:– Can mean “surprised” or “disbelief”Can mean “surprised” or “disbelief”

Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help

ContinueContinue: encourage patient along : encourage patient along same linessame lines

– ““Yes?”Yes?”– ““Uh-huh”Uh-huh”– ““I see”I see”– ““Go on…”Go on…”


Repeating/ReflectionRepeating/Reflection: use when more : use when more information is needed after patient has information is needed after patient has stopped.stopped.– Repeating patient’s last few words in the Repeating patient’s last few words in the

form or intonation of a questionform or intonation of a question– Repeating a phrase used earlier to change Repeating a phrase used earlier to change

a topic which was brushed over a topic which was brushed over Patient: “…and then I had this eye pain.”Patient: “…and then I had this eye pain.”Response: “You had this eye pain?”Response: “You had this eye pain?”


ClarificationClarification: use when a word is : use when a word is ambiguous or confusingambiguous or confusing– ““Tell me what you mean by _____ “Tell me what you mean by _____ “

– Example: DizzinessExample: Dizziness

““Tell me what you mean by dizziness.”Tell me what you mean by dizziness.”

If the patient is having difficulty, give some If the patient is having difficulty, give some examples: “Does the room spin around or do examples: “Does the room spin around or do you get light headed?”you get light headed?”


EmpathyEmpathy: Recognizing and : Recognizing and acknowledging a person’s feelings.acknowledging a person’s feelings.

– Used to show you recognize feelings and Used to show you recognize feelings and are “OK” with them.are “OK” with them.

– ““This must be very difficult for you.”This must be very difficult for you.”


ConfrontationConfrontation: Observation or : Observation or statement to show discrepancies, statement to show discrepancies, especially in affect.especially in affect.

– ““You smile when you tell me that your You smile when you tell me that your mother passed away.”mother passed away.”

– ““You say all is resolved, yet you sound You say all is resolved, yet you sound angry.”angry.”


InterpretationInterpretation: based not upon : based not upon observation but rather upon observation but rather upon inference, linking statements to inference, linking statements to imply cause.imply cause.

– ““It seems that every time you wear your It seems that every time you wear your contact lenses, your eyes are crusted contact lenses, your eyes are crusted the next morning.”the next morning.”


ExplanationExplanation: of why a question is going : of why a question is going to be asked or has been asked.to be asked or has been asked.

– ““When the eyes are this red for this length When the eyes are this red for this length of time, we need to ask other questions of time, we need to ask other questions about your activities and about symptoms about your activities and about symptoms in other areas of the body.”in other areas of the body.”

– IMPORTANT: There is a reason for every IMPORTANT: There is a reason for every question that we as Optometrists will ask. question that we as Optometrists will ask. Know the reasons for them!!Know the reasons for them!!


Summary: Summary:

– Condenses facts and conveys how you Condenses facts and conveys how you understand the patient’s Health/Vision understand the patient’s Health/Vision problems and/or needs.problems and/or needs.

Types of Questions and Types of Questions and StatementsStatements

Open-endedOpen-ended: unstructured, undirected: unstructured, undirected

– Allows the patient to choose own focus, Allows the patient to choose own focus, typical opening question of a case history.typical opening question of a case history.

– Starts with: “What, how, when, where…”Starts with: “What, how, when, where…”

– Example: “What brings you in for an eye Example: “What brings you in for an eye exam today?”exam today?”


ClosedClosed: structured, directed “Yes-No”: structured, directed “Yes-No”

– Seeks specific detailsSeeks specific details

– Starts with “Do you…, Does anyone…, Starts with “Do you…, Does anyone…, Are you…?”Are you…?”

– Example: “Are you taking any Example: “Are you taking any medications?”medications?”


Direct QuestionDirect Question: focuses on specific : focuses on specific informationinformation

– Short answer, can be yes-no.Short answer, can be yes-no.

– Ex: Direct Open – “What type of activities Ex: Direct Open – “What type of activities do you do at work?”do you do at work?”

– Ex: Direct Closed – “Are you currently Ex: Direct Closed – “Are you currently working?”working?”


Indirect QuestionIndirect Question: Open-ended : Open-ended questions that do not sound like a questions that do not sound like a questionquestion

– Ex: “Your glasses are very heavy. That Ex: “Your glasses are very heavy. That must cause you difficulty in school.”must cause you difficulty in school.”


Compound QuestionCompound Question: “Double Barreled”: “Double Barreled”

– Two questions at once. Confusing to the Two questions at once. Confusing to the patient, “which do I respond to?”patient, “which do I respond to?”

– Ex: “Do you ever get headaches or see Ex: “Do you ever get headaches or see double?”double?”

– AVOIDAVOID!!!!


Multiple ChoiceMultiple Choice: “Laundry List”: “Laundry List”

– Provides patient with a list of responses. Provides patient with a list of responses. Used to narrow down the “Time of Used to narrow down the “Time of Onset” or frequency of a Sx. Onset” or frequency of a Sx.

– Good for patients who are unsure how to Good for patients who are unsure how to respond or to control the talkative or respond or to control the talkative or rambling patient.rambling patient.


Multiple ChoiceMultiple Choice cont’d: cont’d: Often used when a patient doesn’t Often used when a patient doesn’t

know an answer to onset or frequencyknow an answer to onset or frequency– Ex: “How often are your headaches? Every Ex: “How often are your headaches? Every

day? Once a week? Twice a week or a few day? Once a week? Twice a week or a few times a week?”times a week?”

– Limits responses and tends to put the Limits responses and tends to put the examiner’s word into the patient’s examiner’s word into the patient’s symptoms.symptoms.


Leading (Suggestive) QuestionsLeading (Suggestive) Questions::

– Suggests the “correct answer”Suggests the “correct answer”

– Ex: “You don’t smoke, do you?”Ex: “You don’t smoke, do you?”

– Judgmental! Don’t use!Judgmental! Don’t use!


Informing QuestionsInforming Questions::

– Asked in a way that information is given Asked in a way that information is given as to why a question was asked.as to why a question was asked.

– Ex: “This medication is usually taken for… Ex: “This medication is usually taken for… ________ is that why you are taking it?” is that why you are taking it?”

– Ex: “Side effects with that medication are Ex: “Side effects with that medication are common for…1,2,3 have you notice any common for…1,2,3 have you notice any of those?”of those?”


Facilitative QuestionsFacilitative Questions

– Shows attention or interest. Encourages Shows attention or interest. Encourages the patient.the patient.

– Ex: “Tell me more about that.”Ex: “Tell me more about that.”


Clarifying Questions and StatementsClarifying Questions and Statements:: 4 Types4 Types

– Used to confirm what was heard and to jog Used to confirm what was heard and to jog patient’s memory for more information.patient’s memory for more information.

ReflectionReflection – Repeat last statement as a – Repeat last statement as a questionquestion

ParaphrasingParaphrasing – shortening phrase in your – shortening phrase in your terms for recordterms for record

CheckingChecking – repeat last statement – repeat last statementSummarizingSummarizing – brief review – brief review


Validation QuestionsValidation Questions::

– To confirm meaning & accuracy. To confirm meaning & accuracy. Involves both observation & Involves both observation & interpretation of cues.interpretation of cues.

– Ex: “You seem worried about those Ex: “You seem worried about those findings…”findings…”


Acknowledging QuestionsAcknowledging Questions::

– Acknowledges your observation and Acknowledges your observation and asks “What would the patient like?”asks “What would the patient like?”

– Ex: “You are nervous about this test. Is Ex: “You are nervous about this test. Is there anything I can do to make you there anything I can do to make you more comfortable?”more comfortable?”


Confronting QuestionsConfronting Questions: : ““State the obvious”State the obvious”

– Acknowledge emotions, conflicts in Acknowledge emotions, conflicts in information, avoiding.information, avoiding.

– Ex: “You say you’re not upset but you Ex: “You say you’re not upset but you sound very angry. We need to clarify sound very angry. We need to clarify this before we go on.”this before we go on.”


““Why” QuestionsWhy” Questions::– Requires the patient to account for Requires the patient to account for

behavior.behavior.– Ex: “Why didn’t you take your Ex: “Why didn’t you take your

medication?”medication?” BEWARE:BEWARE:

Shows Dr’s feelings of helplessness or Shows Dr’s feelings of helplessness or frustrationfrustration

Overtones of accusationsOvertones of accusationsCan antagonize the patientCan antagonize the patientPatient can feel like Dr is finding faultPatient can feel like Dr is finding fault


““Why” QuestionsWhy” Questions cont’d: cont’d:– Typical response: “because” or alibi, Typical response: “because” or alibi,

excuses and rationalizationexcuses and rationalization

– Avoid!Avoid!Shuts down communicationShuts down communication

– Suggestive alternative: “I’m not clear on Suggestive alternative: “I’m not clear on why…”why…”


Patient’s QuestionsPatient’s Questions::

– ClarificationClarification (terms, treatment) (terms, treatment)

Know lay explanation for any jargon you use.Know lay explanation for any jargon you use.May need to write out patient instructions.May need to write out patient instructions.


Patient’s QuestionsPatient’s Questions cont’d: cont’d:

– InformationInformation (Dx, treatment progression, (Dx, treatment progression, risks)risks)

Dr must know the reason for all questions Dr must know the reason for all questions asked.asked.

Dr must be familiar with many different Dr must be familiar with many different diseases/treatments of both ocular disorders diseases/treatments of both ocular disorders and systemic disorders.and systemic disorders.


Patient QuestionsPatient Questions cont’d: cont’d:– Personal questionsPersonal questions

May just wish to know your background as a May just wish to know your background as a personperson

– Best to keep answers to “Yes/No”Best to keep answers to “Yes/No”

ManipulationsManipulations– Patient seeking special care, “your friend”Patient seeking special care, “your friend”– If get more questions after your 1If get more questions after your 1stst “Yes/No,” “Yes/No,”

don’t ask, “Why?” Say: “I believe we are don’t ask, “Why?” Say: “I believe we are here to discuss your eyes and vision….”here to discuss your eyes and vision….”

Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing

We will use these different question We will use these different question styles to open up a patient to give us styles to open up a patient to give us the information we need. the information we need.

By changing or combining these By changing or combining these question types we will be able to question types we will be able to focus a general complain down to the focus a general complain down to the essential information needed to essential information needed to make a diagnosis. make a diagnosis.


Funnel ApproachFunnel Approach Inverted Funnel ApproachInverted Funnel Approach Tunnel ApproachTunnel Approach Repeated Funnel ApproachRepeated Funnel Approach Hourglass ApproachHourglass Approach Diamond ApproachDiamond Approach


Funnel ApproachFunnel Approach This is the standard approach to This is the standard approach to

most patientsmost patients– We start off with a very broad “open” We start off with a very broad “open”

questionquestion– Then we slowly change to more closed Then we slowly change to more closed

questions as we focus down to the questions as we focus down to the details of the problemdetails of the problem


Inverted Funnel ApproachInverted Funnel Approach– Is used for patients who are closed or Is used for patients who are closed or

not sure what or if they have a problemnot sure what or if they have a problem– We start out closed “yes-no” questions We start out closed “yes-no” questions

then to open as the patient opens upthen to open as the patient opens up


Tunnel ApproachTunnel Approach– Is used for those closed patients who Is used for those closed patients who

never open up and for those overly never open up and for those overly talkative patientstalkative patients

– We use a series of repeated closed, We use a series of repeated closed, “yes-no” and list questions“yes-no” and list questions


Repeated Funnel ApproachRepeated Funnel Approach– Is used for patients whom have multiple Is used for patients whom have multiple

problemsproblems– We often have to start over with the We often have to start over with the

open to close questioning for each open to close questioning for each symptomsymptom


Hourglass ApproachHourglass Approach– This is more typical of the approach we This is more typical of the approach we

will take with most of our patientswill take with most of our patients– We start open then focus them down. We start open then focus them down.

Then we open them back up to Then we open them back up to complete the rest of their medical complete the rest of their medical history ending with the summery and history ending with the summery and asking is there anything else to add.asking is there anything else to add.


Diamond Approach Diamond Approach – Is with the Inverted Funnel Approach on Is with the Inverted Funnel Approach on

patients who where initially closed who patients who where initially closed who then opened up we then refocused them then opened up we then refocused them down to find our WDx.down to find our WDx.

TrapsTraps

Ten Traps of InterviewingTen Traps of Interviewing

Nonproductive, defeating verbal Nonproductive, defeating verbal messages that restrict the patient’s messages that restrict the patient’s response:response:

1) Providing Assurance or 1) Providing Assurance or Reassurance Reassurance

– ““Don’t worry, I’m sure it will be all Don’t worry, I’m sure it will be all right.”right.”

Trivializes anxiety and problems.Trivializes anxiety and problems.


2) Giving Advice2) Giving Advice– ““If I were you, I’d do……”If I were you, I’d do……”– Shifts accountability for decisions to Shifts accountability for decisions to

you. Increases YOUR liability.you. Increases YOUR liability.

3) Using Authority3) Using Authority– ““Your doctor knows best”Your doctor knows best”– Promotes feelings of inferiorityPromotes feelings of inferiority


4) Using Euphemisms or Language of 4) Using Euphemisms or Language of AvoidanceAvoidance

– “…“…passed on…”passed on…”– Avoids realityAvoids reality

5) Engaging in Distancing5) Engaging in Distancing– use of impersonal language/speech “We use of impersonal language/speech “We

find…” to erect barriers between you and find…” to erect barriers between you and your patientyour patient


6) Use of Professional Jargon6) Use of Professional Jargon– sounds condescending, excludes sounds condescending, excludes

patient, makes them feel like you are patient, makes them feel like you are talking over their head.talking over their head.

7) Leading or Biased Questions7) Leading or Biased Questions– ““You don’t smoke, do you?”You don’t smoke, do you?”– Judgmental Judgmental – Implies that one answer is “better”Implies that one answer is “better”


8) Talking Too Much/Teaching 8) Talking Too Much/Teaching During HistoryDuring History

– Patient loses train of thoughtPatient loses train of thought– Wastes time Wastes time

most will forget informationmost will forget information

– If exam takes long even due to their If exam takes long even due to their questions the patient still sees you as questions the patient still sees you as inefficient…Competent?inefficient…Competent?


9) Interrupting9) Interrupting– The most common trap doctors fall intoThe most common trap doctors fall into– Cuts patient off, seen as rude?Cuts patient off, seen as rude?– Discourages elaborationDiscourages elaboration

10) Using “Why” Questions10) Using “Why” Questions– Implies blame, condemnationImplies blame, condemnation

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Health & Medicine

Lecture 2